Endometrial Ablation - Indications, Contraindications, and Complications

What Is Endometrial Ablation?

Endometrial ablation is a minimally invasive surgical procedure to destroy the endometrium (uterine lining). This procedure is usually done in women with complaints of heavy menstrual bleeding and bleeding in between periods. For those women, who want to have children in the future, endometrial ablation is not advised due to potential problems.

Endometrial ablation does not require any incisions. The doctor passes thin instruments through the opening between the vagina and the uterus (cervix). Depending on how the endometrium is ablated, different tools are used. Extreme cold, heated fluids, microwave energy, or high-energy radiofrequency techniques are a few examples.

Endometrial ablation procedures can sometimes be performed in a doctor's office. Some have to be done in an operating room. Which endometrial ablation technique is best will depend on factors like the size and health of the uterus.

What Are the Indications for Endometrial Ablation Procedure?

Indications for endometrial ablation include the following conditions-

• Young women (who have already had the desired number of kids) have heavy menstrual bleeding due to benign causes impacting their quality of life.

• Heavy menstrual bleeding can be due to hormonal changes, fibroids, or polyps growing in the uterus.

• Abnormal uterine bleeding (not related to hyperplasia or malignancy).

• Abnormal anatomy of the uterus (abnormal length and contour of the uterine cavity) as identified by the doctors on a preoperative transvaginal ultrasound.

• Before an endometrial ablation, doctors recommend a preoperative benign endometrial biopsy.

What Are the Contraindications for Endometrial Ablation Procedure?

Contraindications for endometrial ablation include the following conditions-

• Pregnancy.

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• Fertility preservation.

• Endometrial hyperplasia or uterine malignancy.

• Active pelvic infection.

• Intrauterine device (IUDs).

• History of uterine surgeries like cesarean section or myomectomy.

• Uterine anomalies like septate, bicornuate, or unicornuate uterus.

• Other relative contraindications include a postmenopausal state, greater uterine cavity length, severe myometrial thinning, or severe uterine retroflection.

How to Get Prepared for Endometrial Ablation?

The patient is counseled and educated regarding the procedure and its outcomes. The uterus is assessed for size, position, and cavity contour with the help of an endometrial biopsy or ultrasound. Any intrauterine devices (IUDs) are removed before the procedure. Endometrial ablation is performed under anesthesia as an outpatient procedure. If the patient is unsure about her pregnancy status, she must take a pregnancy test before ablation to avoid pregnancy-related complications.

How Is an Endometrial Ablation Procedure Done?

Endometrial ablation is a non-invasive technique. Two techniques described for the procedure of endometrial ablation are as follows-

A) First Generation Technique:

Resectoscopic Endometrial Ablation- Performed under hysteroscopic guidance using a loop electrode (rollerball, monopolar, or bipolar). The endometrium is destroyed using thermal energy. Electrosurgery is done with a resectoscope (a thin telescope inserted into the uterus). It has an electrical wire loop, rollerball, or spiked-ball tip to destroy the endometrium (uterine lining).

B) Second Generation Techniques:

Nonresectoscopic Systems- In this procedure, a resectoscope is not required to destroy the endometrium. Second-generation techniques include-

1. Radiofrequency- A probe is inserted into the uterus through the cervix. The probe's tip expands into a mesh-like device that sends radiofrequency energy into the lining. The power and heat destroy the endometrial tissue while suction is applied to remove it.

2. Freezing- A thin probe is inserted into the uterus. Ultrasound is used for guidance; the probe's tip freezes the uterine lining.

3. Heated fluid- The fluid (inserted into the uterus by hysteroscopy) is heated and kept for about ten minutes to destroy the uterine lining.

4. Heated balloon- A balloon with heated fluid is placed in the uterus with a hysteroscope. The balloon expands to touch the uterine lining and destroy the endometrium.

5. Microwave energy- A special probe is inserted into the uterus, which applies microwave energy to the uterine lining to destroy it.

What to Expect After an Endometrial Ablation?

• After an endometrial ablation procedure, recovery takes about two hours.

• Over-the-counter painkillers are advised by the doctor depending upon the type of method used for endometrial ablation. Aspirin must be avoided to prevent bleeding.

• Some common minor side effects after an endometrial ablation are as follows-

  1. Cramps like menstrual cramps for a few days.
  2. A thin watery discharge with blood from the vagina for a few days.
  3. Frequent urination.
  4. Nausea.

• Avoid exercise, sexual intercourse, or tampons for a few days.

• The patient must have follow-up visits to check the progress and effects of ablation.

• Immediate help from the healthcare team should be taken in case of-

  1. Strong-smelling vaginal discharge.
  2. Fever and chills.
  3. Cramping or stomach pain for too long.
  4. Heavy bleeding even after two days of the procedure.
  5. Trouble in urination.

What Are the Complications of Endometrial Ablation?

Postoperative complications after an endometrial ablation are as follows-

• Infection.

• Uterine trauma like lacerations to the cervix or perforation of the uterus.

• Distention fluid overload.

• Thermal injuries like burns to the cervix, vagina, and vulva.

• Pregnancy-related complications like abnormal placentation, premature birth, intrauterine growth restriction, and perinatal mortality.

• Obstructed hematometra.

• Cyclic pain due to residual endometrium.

• Post-ablation tubal sterilization syndrome- This syndrome is characterized by cyclic pelvic pain due to endometrial regrowth and distension of the uterine cornua with blocked fallopian tubes.

• Missed or delayed diagnosis of uterine carcinoma due to scarring and changes seen on imaging after ablation.

• Reoperation with traditional hysterectomy within five years due to bleeding or pain.

• The results of endometrial ablation do not always last. After a few years, menstruation may get heavier and longer again. These women may need a different line of treatment.

Is Pregnancy Possible After Endometrial Ablation?

Pregnancy is not likely after an endometrial ablation procedure, but it can still happen in some cases. A woman, after endometrial ablation, still has all her reproductive organs and thus can get pregnant. Women who get pregnant after endometrial ablation have a high risk of miscarriage and other problems. If a woman wishes to get pregnant, she should not have this procedure. After endometrial ablation, the women should use birth control until after menopause to avoid pregnancy. Sterilization may be an excellent option to prevent pregnancy after ablation.

Conclusion

Endometrial ablation is a gynecologic surgical procedure designed to remove the endometrial lining of the uterine cavity. In the past, heavy menstruation was treated with a hysterectomy (removal of the uterus). Still, endometrial ablation is more advantageous as it can be done quickly, is relatively painless, and requires minimal recovery time. It is an excellent option for women who do not want a major surgery like a hysterectomy.